Clinicians’ perceptions of “enhanced recovery after surgery” (ERAS) protocols to improve patient safety in surgery: a national survey from Australia

Background Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians’ perceptions of ERAS protocols in Australia. Methods A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS. Results The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were ‘very knowledgeable’ (n = 24; 13.6%) or ‘knowledgeable’ (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3–5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%). Conclusion There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints. Supplementary Information The online version contains supplementary material available at 10.1186/s13037-024-00397-w.


Background
Globally, the demand for surgery is high; around 313 million procedures were performed in 2012 [1] and this figure is likely now far higher [2].Due to the invasive nature of surgery, patients are at risk of developing postoperative complications.A global study of patient outcomes after elective surgery across 474 hospitals in 27 countries found that 16.8% of 44,814 patients developed complications postoperatively, including surgical site infection (5%), bleeding (3%), arrhythmia (2.7%) and pneumonia (1.6%) [3].The impacts of such postoperative complications can be far-reaching.For instance, they may result in psychological consequences [4], decreased quality of life [5], increased hospital length of stay and costs [6,7] and mortality [3].Globally, four million individuals die within 30-days of surgery annually, which has been estimated to represent 7.7% of global deaths [2].Subsequently, bestpractice surgical care pathways, guidelines, and protocols have been developed to reduce patients' risk of developing postoperative complications.
Enhanced Recovery After Surgery (ERAS®) protocols were developed based on evidence to reduce perioperative stress and complications and promote early recovery [8,9].A growing body of research has demonstrated the positive impacts of using ERAS protocols compared to traditional care, and there have been several systematic reviews, meta-analyses and an umbrella review supporting the effectiveness of ERAS protocols on reducing hospital length of stay, costs, readmissions and/or complication rates [e.g.[10][11][12][13].First created for colon resection [14], ERAS protocols have now been adapted and updated for multiple surgical specialties (e.g., elective colorectal surgery [15], cardiac surgery [16]) and specific procedures (e.g., pancreaticoduodenectomy [17]).They span the entire surgical journey; and are intended to be multimodal, requiring a multidisciplinary approach with no single element alone improving patient outcomes [9].Specific protocols vary depending on the type of procedure, preoperative components include education, lifestyle changes, nutritional support, dietary interventions, and medication use [15,[16][17].The intraoperative phase includes temperature control, medication use, and minimisation of invasiveness and drains.Postoperatively, patients receive multimodal opioid-sparing pain control, early drain removal, mobilisation, oral fluid intake, and follow-up.Prophylactic measures (e.g., anti-emesis, -microbial or -coagulation) are also included across surgical protocol phases.
However, despite the benefits of ERAS protocol use [13], their free availability [8] and their uptake internationally, wider adoption in the Australian context has been slow or incomplete [18].There is a myriad of reasons for this, including the complexity of ERAS implementation and its resource-intensive nature.Internationally, barriers to ERAS protocol implementation include resistance to change from frontline clinicians, limited implementation resources, and external factors (e.g., patient complexity, rural location) [19].Another key barrier in Australia may be the fragmentation of care delivery between different phases of the surgical journey such as preadmission versus perioperative phases versus surgical ward care [18].Selection and prioritisation of only some components as opposed to implementation of a protocol in its entirety is another challenge in ERAS implementation [20,21], which may result for reasons such as a lack of surgery-or specialty-specific ERAS protocols in some areas.
Compounding these barriers has been the lack of a nationally coordinated approach to ERAS implementation and compliance monitoring in Australia, as opposed to the governmental support observed in Canada, the United Kingdon, New Zealand and the United States [20].National approaches to drive sustained ERAS implementation in such countries are only recently emerging, including the establishment of a national ERAS Centre of Excellence [22] and state-based government guidance and support [23][24][25].This means that ERAS implementation in Australia remains in the early stages, with the impetus for implementation previously dependent upon individual motivated clinicians and facilities.At the clinician level, awareness and agreement with clinical practice guidelines precedes their adoption and adherence [26,27].However, the extent of clinicians' perceptions of ERAS protocols in Australia is unknown.A recent study examined colorectal surgeons' attitudes towards ERAS interventions in Australia and New Zealand [28], but this was limited to rating the perceived effectiveness of individual ERAS components and other clinicians were not included.A broader investigation may reveal important insight into the lagging adoption of ERAS protocols.There is a need to explore this knowledge gap to inform the development of strategies to promote and enable more consistent implementation of ERAS protocols in the Australian context.

Aim
This study aimed to describe and compare clinicians' (anaesthetists, surgeons and nurses) perceptions of ERAS protocols in Australia.Subsumed in this overarching aim were the following objectives:

Design
A descriptive national online survey of surgeons, anaesthetists, and perioperative and surgical nurses was undertaken.Its reporting was guided by the Checklist for Reporting of Survey Studies (CROSS, Supplementary file S1) [29].The involvement of consumers as co-investigators and partners in conducting the survey was guided by the principles of consumer partnerships in research [30] and reported using the Guidance for Reporting Involvement of Patients and the Public short-form checklist (GRIPP 2; Supplementary file S2) [31].

Sample
The target population was healthcare professionals from surgery, anaesthetics, perioperative and surgical nursing who were currently practicing in Australia.  1 shows the eligibility criteria.

Survey instrument
The study survey instrument was adapted from Beal et al's [32] The demographics section had 14 items including age; sex; location; healthcare sector, type of facility, department, specialty and unit of work; current role and years in role.Department, specialty and role items were nuanced towards either nurses or anaesthetists and surgeons (see Supplementary file S3).A screening question was also included at the beginning of the nurse survey; "Do you currently work in a setting that provides post-operative surgical care?" (yes/no; if no survey ended).Additionally, if any participant's response indicated their current facility was not located in Australia, the survey ended.Finally, the demographics section measured whether respondents had participated in the care of a patient using an ERAS protocol previously.Perceptions of ERAS included seven items with responses measured on a 5-point Likert scale to indicate participants' degree of perceived knowledge (1 = Very unknowledgeable, 5 = Very knowledgeable) and their beliefs of the benefits of ERAS (1 = Strongly Disagree; 5 = Strongly Agree).Knowledge of ERAS focused Table 1 Eligibility criteria • Anaesthetists and surgeons currently practicing in Australia in any specialty.
on education and learning and had five items with multiple choice questions relating to reasons for ERAS design, interest in and preferred method of ERAS learning, need for formal ERAS education for each profession, and barriers to gaining ERAS knowledge.Finally, the future planning section had two items, one measuring whether ERAS protocols should be implemented broadly and if so, for which populations, and one free-text item for additional comments or thoughts.

Data collection
Permission to access prospective survey respondents was granted by professional organisations that distributed the survey to fellows and members on behalf of the researchers via their regular email communications.Emails were sent to all active fellows and members (≈ 22,940 total), although it was unclear how many members and fellows were eligible to respond.Emails contained a brief invitation and link, which guided respondents to the participant information sheet, followed by the survey, all hosted within the Research Data Capture (REDCap) data management system [33].Respondents were able to exit the survey at any time by closing their browser.The online platform used to host the survey recorded all data entered in the survey, including incomplete responses.Therefore, if a participant provided consent but did not fully complete the survey, their data was retained for analysis.
Recruitment was active from July to November 2023.After the initial invitation was sent to organisation fellows and members, with two follow-up invitations sent.Given the large number of fellows and members, and distribution of the invitation via professional organisations, there was no individual or identifiable tracking of who received, opened, or completed the survey.Several members of the research team also regularly posted invitation links to the survey on X, Inc™.

Data analysis
Data were exported from REDCap into Microsoft Excel™ for cleaning, and response rates calculated.Data were then imported into IBM SPSS™ (Version 29) for further analysis.Descriptive statistics were used to summarise the data, with frequencies (counts and proportions) used to report categorical data.Summary statistics using means and standard deviations or medians and interquartile ranges (IQR) were used for continuous data, depending on their distribution.Ordinal 5-point Likert scale responses were described using counts and proportions, and an overall median, interquartile range and range.Differences between the three professional disciplines were examined using Pearson Chi-square, Fisher's Exact, one-way between-groups analysis of variance, or Kruskal-Wallis tests, where appropriate and based on assumptions.Pearson Chi-square (with Yates Correction for 2 × 2 tables) tests were used to compare associations between perceptions of ERAS and nursing departments (perioperative and surgical ward/unit).Statistical significance was set at p <.05.

Survey responses
A total sample of 178 was included, comprising 116 (65.2%) nurses, 36 (20.2%) surgeons and 26 (14.6%) anaesthetists (see Fig. 1).Of these, 23 (12.9%) had large amounts of missing data, with these respondents completing the survey to the end or beginning of the 'Demographics' and 'Perceptions of ERAS' sections, respectively.Cases of missing data are reported in the results tables.

Sample characteristics (objective 1)
Table 2 describes characteristics of the sample.Respondents were located across six states and two territories, with nurse and surgeon respondents in all.There were significant differences across professions in terms of sex, adult and paediatric operating theatres in respondents' facilities and specialties worked within (Table 2).Over three-quarters of nurses were perioperative as opposed to surgical.Almost 60% of respondents reported previously participating in the care of a patient who was on an ERAS protocol.There was a significant association between reports of previously participating in the care of a patient who was on an ERAS protocol and profession (χ 2 [2, n = 177] = 40.96,p <.01, Cramer's V = 0.48; Table 2).These results indicated that fewer than 50% of nurses had participated previously, while all anesthetists and over 80% of surgeons had previously participated in ERAS protocols.

Beliefs about ERAS
The level of agreement about the benefits of using ERAS among respondents was neutral to strongly agree.Most respondents perceived that ERAS protocols improve patient care and institution financial efficiency and are a reasonable time investment (Supplementary file S4), with overall medians ranging from 3/5 to 5/5 across statements.There were significant differences between professions for most statements (n = 5), with nurses generally recording lower levels of agreement (Table 3; Supplementary file S4).Pairwise post hoc comparisons suggested that differences between surgeons and anaesthetists were not significant for any statements.However, there were significant differences between nurses and anaesthetists (n = 1), surgeons (n = 1) or both (n = 3) (Table 3).Statement scores were not associated with nurses' department (perioperative and surgical ward/unit).

Knowledge (education and learning preferences) of ERAS protocols (objective 3)
Table 4 summarises participants' responses to the 'Knowledge of ERAS' survey component.Respondents were most interested in learning about minimising perioperative complications and least interested in learning about improving perioperative efficiency, with significant associations between profession and interest in learning about fluid management and minimising perioperative complications (Table 4).Post hoc pairwise comparisons using Bonferroni correction indicated significant differences between nurses and anaesthetists for both (p =.003 and p =.001, respectively).Most respondents indicated their preferred method to learn about ERAS® was via seminars or lectures from national or international leaders overall and across professions (Table 4).However, more surgeons indicated they would prefer to learn via direct participation in protocols and reviewing journal articles or textbooks.Post hoc group comparisons indicated group differences were significant (n = 143, p =.031; Table 4).Nearly all respondents supported formal education on ERAS® for upcoming nurses, followed by training for surgeons and anaesthetists.However, significantly fewer anaesthetists supported such training for upcoming practitioners in their profession.More nurses than anaesthetists and surgeons perceived that lack of information was a barrier to gaining ERAS knowledge (χ 2 [2, n = 155] = 10.33,p =.006, Cramer's V =.258).

Future planning (objective 4)
Most respondents supported the broad implementation of ERAS protocols (n = 130, 87.8%).Support was similar across professions (anaesthetists n = 22, 100%; surgeons n = 28, 90.3%; nurses n = 80, 84.2%; n = 148, p =.107).Of those that supported implementation of ERAS protocols, 86 (66.2%%) provided further comment on the populations where ERAS should be implemented.Of those 86, supported groups for implementation were all or almost     Of those that did not support broad ERAS implementation, 44.4% (n = 8/18) provided further comment.Four specified that they either did not know enough about ERAS to answer (50%), while the remaining four specified that only certain ERAS principles were relevant, that it depends on the surgery and patient, that nurses lose critical thinking skills and knowledge due to everything becoming 'ticking a box' , or that protocols are difficult to implement during short pre-operative periods, in limited length of stay procedures and within pre-existing local procedures.

Further comments (objective 5)
In addition to the comments presented in the previous section, there were a further 49 survey comments.Comments ranged from detailing local practices that may already incorporate components of ERAS, 'selective' implementation and benefits of ERAS to the identification of barriers and facilitators.Several respondents indicated they or their colleagues had limited or no awareness of ERAS protocols (n = 10, 5.62%).

Barriers and facilitators to ERAS implementation
There were several barriers and facilitators to ERAS implementation identified in the comments, (Table 5).Major barriers related to lack of knowledge and understanding of benefits, lack of interest and support from senior administration, managers, and clinicians for implementation and standardisation, resource requirements and a lack of ability to adapt content based on patient needs.

Summary of results
This study has provided important baseline insights into the current state of ERAS perceptions across Australia and has described clinicians' preferences for education and learning that can inform future ERAS implementation efforts.Overall, clinicians reported perceiving ERAS protocols in a largely beneficial light, with most also indicating they were 'knowledgeable' and had previously cared for a patient who was on an ERAS protocol.However, there were several key results and significant differences between professions that warrant further discussion.

Adoption of ERAS protocols
All anaesthetist and most surgeon respondents indicated that they had previously participated in the care of a patient who was on an ERAS protocol.This is greater than the adoption found in a previous survey of colorectal surgeons and perioperative care in Australia and New Zealand, where 55% of 76 respondents did not care for patients using an ERAS protocol, 37% routinely did, and 8% did 'sometimes' [35].More recently, researchers have reported ERAS implementation and/or use in Australian facilities [e.g.36,37,38], along with the establishment of a local ERAS Centre of Excellence [22].These resources, and our more contemporary results, suggest that ERAS uptake may be increasing.
It has been estimated that evidence takes up to 17 years to be translated into clinical practice [39], and support for the benefits of ERAS protocols has now been building for over a decade.The lag or gap between what is known and what is done, or the diffusion of innovation into the system and its members, has long been acknowledged as a challenge across many fields [40].In other areas of health care, use of clinician practice guidelines may be lost across a four-stage pipeline: awareness, to agreement, to adoption, to adherence, and the simple 'availability' of a guideline does not result in complete uptake [26,27].To overcome the recognised evidence to practice gap [26,39], translational efforts must support implementation  Note: a pairwise: significant difference between nurses versus surgeons/ anaesthetists; b pairwise: significant difference between nurses versus anaesthetists; c pairwise: significant difference between nurses versus surgeons; ERAS = Enhanced Recovery After Surgery; IQR = interquartile range.Missing data* 12.9%, 14%, 14%, 12.9%, 12.9%, 14%  into real-world contexts, particularly in the complex health care environment [41].

Perceived knowledge about ERAS
Our results suggest that nurses' perceived knowledge level was also lower than that reported by anaesthetists and surgeons.Nurses play a pivotal role across all phases of the patient's surgical journey including contributing to and coordinating care directly related to ERAS components [42].Their lack of awareness and knowledge of ERAS may suggest that protocols are often only partially or selectively implemented locally, which is a controversial approach to implementation not isolated to Australia [20,21].In a systematic review and meta-analysis of trials testing ERAS versus usual care for colorectal surgery in adults, protocols from 25 trials included a variation of between 4 and 18 elements [20].Similarly, some of our survey respondents indicated that there is a need to be able to adapt interventions to individualise care.However, this contrasts with the multimodal, multidisciplinary principles of ERAS in which the intended approach is to include all elements as they have supporting evidence of improving patient outcomes [21].The exclusion of certain evidence-based ERAS elements may limit patient benefit, and facilities should include as many as possible [21].

Beliefs about ERAS
Respondents rated their beliefs around ERAS positively, although nurses less so, which may suggest limited knowledge rather than disagreement.Similarly, Beal and colleagues [32] found that most perioperative clinicians surveyed in their United States tertiary medical centre 'strongly' or 'very strongly' agreed that ERAS protocols were important for patient care, that their colleagues and administration felt the same, and that having patients involved in ERAS improved care.However, while our results indicate clinicians largely understand the benefits of ERAS overall, there are variations in support for ERAS.
In other areas, disagreement with clinical guideline components may result in failed adoption and adherence [26], and this may also limit ERAS uptake.A recent survey of Australian and New Zealand colorectal surgeons (n = 95) attitudes towards the effectiveness of 18 ERAS protocol components on short-term outcomes found that, for five interventions, 50-57% of surgeons felt they were 'definitely' or 'very likely' to be effective, but the remaining interventions had < 50% support to as low as 1-2% support [28].Wide variations in implemented ERAS protocol components have been reported elsewhere [20], and there is a need to focus on the benefits of implementing ERAS protocols in their entirety in future research and educational strategies.

Knowledge of ERAS: education and learning
Our survey also provided insights into the educational and learning preferences of respondents, which may be used to target and nuance implementation strategies.Our results suggest that Australian clinicians value patient-focused outcomes, with respondents most interested in learning about minimising perioperative complications versus least interested in improving perioperative efficiency (i.e., improving operational processes, while maintaining quality and safety, to optimise productivity and minimise costs and resource requirements [43]).Our results accord with Hughes and colleagues' [44] multinational survey of patient and care provider attitudes to ERAS after major abdominal surgery across three centres in Scotland, Norway, and The Netherlands.All respondents rated outcomes highly on an 11-point Likert scale (0 not important to 11 very important; medians ≥ 7/11), with care providers and patients rating nausea control and the absence of pain at rest the most important.ERAS strategies were also rated highly, with preoperative counselling rating highly for providers and patients, and promoting and scheduling early mobilisation and avoiding hospital-acquired infection considered the most important for each cohort, respectively.However, higher support for all tested components contrasts with the results of Toh et al. 's [28] survey of Australian and New Zealand colorectal surgeons, where there was little support for the effectiveness of some.Given that some clinicians rated themselves as unknowledgeable about ERAS or commented that their colleagues had limited awareness of ERAS protocols in our survey, education is important and has been credited as a contributor to successful ERAS implementation elsewhere [45].

Barriers and facilitators to implementation
ERAS protocols are complex to implement, given that full adherence involves the simultaneous implementation of all components and interventions among many healthcare providers across healthcare services [46].While education is important, this alone will not bridge the knowledge to practice gap, and the effort required to appropriately implement ERAS protocols should not be underestimated [21].Barriers identified in our survey are congruent with those experienced internationally [19], where resistance to change, limitation in resources, and external factors such as patient complexity and rural location have been highlighted.In the Australian-based context, larger centre health services may face greater challenges in implementing ERAS compared to smaller single site facilities where there may be greater familiarity with surgical care pathways.Other barriers we have identified include the lack of interest and support from seniority and the inability to adapt content; similar to other older Australian studies [35,47,48].Based on our own experience, gaining support from senior management to implement ERAS protocols into policy and source funding for coordinators and multidisciplinary support are significant barriers, while frontline clinicians are unable to be heavily involved due to workloads, despite their interest.Conversely, engaging support from clinicians and hospital leadership is a recognised facilitator for ERAS implementation, along with adaption to fit the local context, demonstrating early achievements, establishing a strong and regularly meeting ERAS team, and utilising ERAS supporters and dedicated staff [19].These international facilitators are relevant to the Australian context and similar to those identified by our respondents, with the addition of compliance monitoring using quality indicators and improvement feedback, which is an important strategy for implementing and sustaining ERAS system-wide [49,50].
From a patient perspective, our consumer investigators indicated they felt that implementation of ERAS was important for future patient care and safety.Inclusion of patients as stakeholders in future ERAS implementation and design is important to give patients agency in their own care, while patient experiences and perceptions shape the surgical care journey and influence compliance.Co-design with stakeholders, from senior management to patients, may be key to gaining insight into addressing these issues.

Limitations
We acknowledge this study has several limitations.There may be some selection bias due to the sampling approach as only clinicians who were members of a professional college were invited to participate.Moreover, nurses were more highly represented than anaesthetists and surgeons in the sample, however all Australian states and two of three territories were represented.There may be limited external validity of our survey results beyond the specific sample.Further, it was not possible to calculate the response rate as precise membership numbers across the peak professional bodies fluctuate, therefore the accuracy of membership numbers at any time is variable.However, approximate membership numbers suggest the proportion who responded to our survey was small.As there was no individual or identifiable tracking of who received, opened, or completed the survey, there is a chance that clinicians could have provided multiple survey responses, but this is unlikely.Finally, there is the possibility of response bias due to social desirability, however, the anonymity measures that were used likely mitigated its effects, ensuring more accurate and reliable data collection.

Conclusion
Our results suggest the need to promote ERAS use and provide education at a clinician and facility level.Our survey results also provide important insight into the preferred methods for learning about ERAS across professions.If clinicians have a better understanding of the principles and benefits of ERAS, they are more likely to advocate and use ERAS, leading to better patient outcomes.This is particularly relevant for nurses, who are well situated to contribute to and coordinate ERAS throughout the surgery journey [42], but who had lower knowledge levels and less experience with ERAS.While education will help in improving ERAS protocol knowledge and implementation, there is also a need to codesign implementation strategies with stakeholders that target identified facilitators and barriers.

Table 2 (
continued) not appropriate for specific patient groups or that use should be selective based on patient circumstances.

Table 4
Knowledge of and future planning for ERAS

Table 5
Barriers and facilitators to ERAS implementation